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Model Part C/EHDI Coordinated Consent Form. Jeff Hoffman, MS, CCC-A National Center for Hearing Assessment and Management EHDI Network Consultant 402-484-0265 [email protected]. Purposes. Coordinated Consent Form - PowerPoint PPT Presentation
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Model Part C/EHDI Coordinated Consent Form
Jeff Hoffman, MS, CCC-ANational Center for Hearing Assessment and
ManagementEHDI Network Consultant
PurposesCoordinated Consent Form
• Recent surveys of EHDI and Part C coordinators (Behl, Houston, & White, 2008; Greer, 2008)– Nearly 60% of EHDI programs rarely or never notified
when children with hearing loss were enrolled in Part C programs
– Remaining 40%, data is incomplete or provided for only part of the children with hearing loss
– Approximately 35% of Part C programs share IFSP information with EHDI programs
– Only a few EHDI programs receive information from Part C about services provided
The Impact of Privacy Regulations: How EHDI, Part C, and Health Providers Can Ensure that Children and Families Get Needed Services
National Center For Hearing Assessment and Management, 2008.
Purposes
Part C/EHDI Workgroup
• Develop a draft model Part C/EHDI coordinated consent form– Streamline the authorization to exchange
child-specific information among providers– Support the coordination of services for the
child and family– Serve as model for consideration by state
Part C and EHDI programs
Participants
Coordinating Workgroup
Randi Winston, AuD; Todd Houston, PhD, Susie
McCamy, MS, Jeff Hoffman, MS (lead)
Workgroup Invitees
Part C and EHDI Coordinators
Connecticut Utah
Illinois Nebraska
Iowa Arizona
Tennessee
Participants
State Part C EHDI
Connecticut Yes Yes
Illinois Yes Yes
Iowa Yes No
Tennessee Yes Yes (designee)
Utah Yes Yes
Nebraska Yes Yes
Arizona Yes (designees) Yes
Workgroup Process
• Background materials provided• Nebraska Consent Form (1994) provided
as starting point for discussion• Email input and suggestions• Two conference calls to discuss format
and content• Synthesis document with considerations
available via email for critique and comments
Draft Model Part 1 – Identifying InformationInitiating AgencyContact PersonAgency AddressPhone Number
Child’s First NameChild’s Last NameChild’s Date of BirthChild’s Birth HospitalChild’s Birth PlaceChild’s Social Security Number
Parent/Guardian Full NameParent/Guardian Date of Birth
Draft Model Part 2 – Type of Information
I give my consent, as the parent/guardian of the minor child, to the agencies identified below to share the information that I have indicated. The purpose of this exchange of information is to help coordinate services, provide appropriate programs, and to make sure that my child and family get services as quickly as possible.
INITIALS TYPE OF INFORMATION____ Health Information Birth Records ENT Records Other (specify)________________________________________________ Screening Results Bloodspot Hearing Other (specify)________________________________________________ Diagnostic Assessments Audiology Speech-Language Other (specify)_______________________________________________ Early Intervention Records IFSP Assessments Other (specify)_______________________________________________ Therapy Reports/Records (specify)________________________________ Educational Records (specify)____________________________________ Other information (specify)___________________________________
Draft Model Part 3 – Agencies & ProgramsListed below are a number of agencies that provide services for children with
special needs and their families. I am putting my initials next to the agencies that I want to share information identified above. I understand that these agencies will use and keep information confidential about my child.
INITIALS AGENCY/PROGRAM____ Part C Early Intervention Program________________________________ Early Hearing Detection & Intervention/Newborn Hearing Screening
Program______________________________________________________ State School for the Deaf (specify)________________________________ Family Support (specify)________________________________________ Early Care/Education Early Head Start Other (specify)____________ Hospital (specify)______________________________________________ School District (specify)_________________________________________ Department of Public Health Vital Records Birth Defects Other (specify)_______________________________________________ Children with Special Health Care Needs (specify) __________________ Department of Social Services (specify)___________________________ Other (specify)________________________________________________ Other (specify)____________________________________________
Draft Model Part 4 – Informed, Signed Consent
I understand that: 1) I have the right to withdraw my consent at any time by writing to the Initiating Agency listed above; 2) I have the right to inspect and copy the information to be shared; 3) If I do not give my consent to share information, the agencies may not be able to determine the best services available for my child and family; and 4) I am providing my consent voluntarily and I understand the information on this form.
Signature of Parent/Guardian______________________________________Relationship to Minor Child_______________________________________Date___________________________________________________________Street Address__________________________________________________City/State/Zip___________________________________________________Phone Number(s)________________________________________________
Unless otherwise stated, the release/request is valid for one year from __________ to_______.
Information shared by the agencies above will not be disclosed to anyone else without written consent of the parent/guardian. This information will never be used to solicit services or products.
Workgroup Considerations
• Amount of information
• Parent understanding
• States differ on key variables
• Scope of agencies listed
• Timing of initiation of consent form
• Gatekeeper
• Training